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Infection & Prophylaxis Pharmacotherapy

Antimicrobial pharmacotherapy across the perioperative window, UTI treatment, recurrent-UTI prevention (antibiotic and non-antibiotic), antifungals, and device-specific infection protocols (IPP, AUS, mesh). Two paradigms have shifted the field in the last few years: the non-antibiotic prevention paradigm for recurrent UTI (vaginal estrogen, methenamine, cranberry) anchored on the AUA/CUA/SUFU 2022 guideline and the ALTAR / ImpresU / Tan-Kim trials; and the PUMP/Barham contemporary IPP-protection protocols that go beyond the AUA recommendations.

For perioperative pharmacology by surgical phase (bowel prep, VTE prophylaxis, anticoagulation reversal, stress-dose steroids, postop ileus management) see Perioperative ERAS.

  • Perioperative Antibiotic ProphylaxisAUA 2020 BPS framework; preoperative urine culture and the IDSA 2019 ASB split (endoscopic vs prosthetic); TOCUS 2024 positive-culture OR 3.68 for febrile infection; national IPP/AUS adherence trends (Brant 2023, Sun 2023); prostate biopsy TR vs TP (NORAPP 2022 Lancet ID non-inferiority); Thurnheer 2024 JAMA Netw Open RCT on PAP duration after radical cystectomy.
  • UTI Treatment AntibioticsStratified by uncomplicated vs complicated UTI; local antibiogram + renal function drive selection. Pivmecillinam (Pivya, FDA 2024) and gepotidacin (Blujepa, FDA 2025) as first-line additions; cefepime-enmetazobactam, plazomicin, and cefepime-taniborbactam (CERTAIN-1 NEJM 2024) for MDR; IDSA 2025 four-step empiric framework with ≥ 90% / ≥ 80% local-antibiogram thresholds; 7-day bacteremia shortening.
  • UTI Suppressive & Prophylactic TherapyAUA/CUA/SUFU 2022 + WikiGuidelines 2024 stepwise framework. Vaginal estrogen first-line in postmenopausal women; ALTAR non-inferiority RCT of methenamine vs daily antibiotics; ImpresU 2025 placebo-controlled phase IV with the post-discontinuation rebound; Jent 2022 antibiotic-prophylaxis meta (85% reduction); continuous / post-coital / self-start regimens; OM-89 / MV140 / Urovac immunoprophylaxis.
  • Non-Antibiotic UTI PreventionHan 2025 network meta (50 RCTs / 14 interventions) anchor; vaginal estrogen with Tan-Kim 2023 n = 5,638 real-world 51.9% reduction; methenamine pharmacology with the urea-splitter caveat; cranberry with Stonehouse 2025 whole-fruit-powder RCT (52% reduction); MERIT-negative D-mannose; vitamin D via cathelicidin; intravesical HA/CS; Kwon 2026 intravesical-aminoglycoside meta (IRR 0.23).
  • AntifungalsFluconazole, amphotericin B, echinocandins. Prosthetic infection prevention (PUMP 92% reduction); candiduria; ascending fungal UTI; perioperative prophylaxis in immunocompromised patients undergoing reconstructive surgery.
  • Prosthetic Infection & BiofilmDevice-specific infection management for IPP, AUS, mesh, and sling. The biofilm-formation timeline and antibiotic-coated-implant evidence; PUMP/Barham revision protocols; salvage vs explant decision-making; staged reimplantation.